Letter to the Editor: Prescribing nicotine replacement therapy to parents is within
pediatricians’ purview

Letters to the Editor

I was dismayed to read the Pediatricians and the Law Q&A in the April issue of AAP News (http://www.aappublications.org/news/2016/03/25/Law031016), which included a question regarding prescriptions of nicotine replacement therapy
(NRT) for parents. The author, Jonathan M. Fanaroff, M.D., J.D., FAAP, indicated several
concerns with prescribing NRT, including NRT being out of the scope of pediatric practice,
concerns about adverse events from NRT, creation of a physician-patient relationship
which may create liability for unrelated illnesses, and issues related to communicating
with an adult patient’s medical home.

As a practicing physician scientist involved in tobacco control, I have carefully
read much literature surrounding the rigorous testing of NRT over a 30-year period.
This literature resoundingly supports the use of NRT with exceedingly rare serious
adverse events. Side effects are due both to the pharmacological action of nicotine
itself (which is in the tobacco product that NRT is designed to replace) as well as
to the mode and site of NRT delivery. Hiccups and gastrointestinal upset are the most
common side effects and tachycardia/heart palpitations the most common cardiac side
effect. There is no excess risk for serious cardiac events with NRT, even among patients
with a high risk of cardiac problems (Mills EJ, et al. Circulation. 2014;129:28-41).

NRT is so safe that it is available over the counter. A written prescription from
a licensed practitioner allows a patient to obtain NRT through his or her insurance
often at a much lower cost or to use a health savings account for its purchase. NRT
“by prescription” is in no way different than what can be simply asked for at the
pharmacy counter without a prescription. Many state quitlines and some retail pharmacy-based
clinics provide NRT through standing orders, too. Aiding parents with a prescription
removes a barrier to one of the most cost-effective preventive health interventions.

It would be ideal to communicate with the adult’s medical home. However, since any
adult can obtain NRT without prescription, the concern about the communication with
the adult patient’s medical home is somewhat spurious.

The American Medical Association also has had policy since 2005 that supports pediatricians
addressing parental smoking (H-490.917: Physician Responsibilities for Tobacco Cessation. Adopted by House of Delegates, June 2005. Chicago, Ill.).

As to scope of practice, it is important to remember that the rate of tobacco use
among high school students is 24.3% (Arrazola RA, et al. MMWRMorb Mortal Wkly Rep. 2015;64:381-385). Tobacco use is a pediatric disease, so well within our scope and
charge to both treat and prevent. Extending this practice to the parents of our patients
is not something to be feared but to be encouraged.

Terms of Use
The American Academy of Pediatrics (AAP) takes the issue of privacy very seriously. See our Privacy Statement for information about how AAP collects, uses, safeguards and discloses the information collected on our Website from visitors and by means of technology.FAQ